A 46-year-old man presented to the emergency department with a 2-day history of dyspnea on exertion, orthopnea, productive cough, and pleuritic chest pain. He had no fever or chills. His medical history was significant for type II diabetes mellitus and acute myocardial infarction. Current medications included aspirin, enalapril, atorvastatin, metoprolol XL, and metformin. He had a 40-pack-year history of cigarette smoking. He had no history of alcohol or IV drug use. He was married and had no risk factors for HIV infection. A review of systems revealed decreased appetite, a 25-lb weight loss over 2 weeks, and intermittent dysphagia for 2 weeks. He had no skin lesions, skin tightening, heart burn, arthralgias, hematuria, or history of cytopenias.